Update of Existing Recipient Information

UPDATE OF EXISTING RECIPIENT INFORMATION

This document is to be completed annually to update the recipient's information.
PART A - Recipient Information/Demographics
Program*
YesNo
TRACCS Record ID
NDIS Reference No:
(if applicable)
CairnsTownsvilleMackayCharters TowersMount IsaPalm IslandInghamRockhamptonSarinaMoranbahLongreachAyr/BurdekinBowenRichmondDoomadgeeNormantonMornington IslandOther
Date*
YesNo
If "Yes", for what language
YesNo
1. Recipient Details
Recipient Name*

First NameLast Name
Date of Birth*
Country of Birth
Phone Number/s*
Use (,) to separate phone numbers
Email
example@example.com
Update of existing recipient informationChange of address/WHS Form
2. Living Arrangements
Home ownerPrivate rentalRental - Department of HousingRental - Coast to Country Housing AssociationNo fixed address - couch surfingNo fixed address - homelessNo fixed address - temporary accomodationOther
No (This may require support)Yes
3. Recipient Details Continued
Residential Address*

Street Address

Street Address Line 2

CityState

Postal Code
YesNo
Postal Address

Street Address

Street Address Line 2

CityState

Postal Code
YesNo
Next of Kin Name*

First NameLast Name
Next of Kin Phone Number*
YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
PART B - Permission Forms

The following forms can be provided for the recipient to read and review before signing. These documents can be copied and provided back to the recipient when presented with the ISP & ISA.
1. Consent to Collect & Use Personal Information
What does this mean?

selectability collects personal and other information from you to help us determine whether we can provide the services you need.

As a person that we support, selectability will also collect and use your information to help us develop and improve the quality of our services.

If you do not consent to selectability collecting and using your information, selectability will not be able to assist you with the services you have requested.

Consent to collect and use your information

selectability aims to protect the privacy and secure storage of your information. You can view our Privacy Policy on our website www.selectability.com.au or request a copy of our Privacy Policy, which includes information about the collection, use and disclosure of your information.

By signing this consent form you authorise selectability to use, store, release, exchange your information with your lifestyle support workers, other service providers, health and medical practitioners and other government agencies to support the services we provide to you and to comply with selectability’s legal obligations.

When we need to pass on your personal information

Your personal information will be kept private and confidential however, there may be times when selectability considers they have a legal obligation to share your information with third parties if:
- You are likely to harm yourself or another person
- A child may be at risk of sexual, physical or emotional abuse, or neglect
- There has been a criminal act that has been committed
- Failure to disclose the information would place you or another person at serious and imminent risk (e.g. emergency)
- selectability is required by law to release your information (e.g. your records are subpoenaed by a court of law)
Information release to help you

On occasions selectability may need to contact and/or exchange information relating to your services with other service providers, organisations and agencies. These may include:
- Centrelink
- Qld Department of Communities, Child Safety and Disability Services
- Office of the Public Guardian (OPG)
- Legal Authorities, Probation and Parole, Department of Justice
- Other Government Agency
- Treating Doctor
- Specialist Providers, Psychiatrists and Psychologists
- Community Mental Health Case Worker
- Employment Provider
- Emergency Contact
- NDIS
If you do not wish selectability to contact and/or exchange information with other organisations, please let us know by emailing feedback@selectability.com.au or speak to a selectability employee.

Marketing information

In some circumstances selectability may want to use your personal information (such as your contact details) to send you newsletters or promote other services that relate to the service being provided to you by selectability.

You have the right to ask selectability not to use your information to send you newsletters or promotional information.
YesNo
If, at any time, you change your mind about receiving marketing information from us you can email feedback@selectability.com.au or speak to a selectability employee.
Recipient Consent

I consent to selectability collecting and using my information for the purposes outlined above for providing services to me and to help improve the quality of their services.
Recipient Signature
YesNot Applicable - signature provided
Please provide reasoning why verbal consent is necessary:
Recipient Name*

First NameLast Name
Date*
YesNo
Legal Representative Signature
Legel Representative Name

First NameLast Name
Date
OPG consent on file
Mainstream Community Supports

2. Carer or Advocate Nomination Form
Why you need to complete and sign this form

Close family members or other significant people in your life are often vital in assisting in meeting your goals. We generally refer to these people as ‘carers’.

They often have important information that they can share with us which will assist you with receiving services from selectability.

This form gives you the opportunity to identify who you would like to have involved in your care, and what and how much information you are happy for us to share with them.

Please nominate the person or persons that we can include in discussions about your service delivery agreement and identify the level of information you would be happy for the staff to share with these people.
1. *Personal Information = you allow us to discuss anything with this person.
2. *Non-Personal Information = general information that allows us to discuss your treatment, support, careplan and medications but not personal information disclosed in the course of therapy.
NB: Personal information about your thoughts and feelings or your history will not be discussed with anyone without your express permission.
YesNo
Carer/Advocate Name*

First NameLast Name
CarerAdvocate
Personal InformationNon-Personal Information
Carer/Advocate Phone Number*
Carer/Advocate Email Address*
example@example.com
Carer/Advocate Name

First NameLast Name
CarerAdvocate
Personal InformationNon-Personal Information
Carer/Advocate Phone Number
Carer/Advocate Email Address
example@example.com
Carer/Advocate Name

First NameLast Name
CarerAdvocate
Personal InformationNon-Personal Information
Carer/Advocate Phone Number
Carer/Advocate Email Address
example@example.com

Recipient Signature
YesNot Applicable - signature provided
Please provide reasoning why verbal consent is necessary:
Recipient Name*

First NameLast Name
Date*
Witness Signature
Witness Name

First NameLast Name
Date
OPG consent on file
3. Release for Use of Images or Recordings

For general publishing or on selectability social media and selectability website
1. Consent

I give consent to selectability to use and retain images or recordings that may identify me for use on the selectability website and/or selectability social media (Facebook, LinkedIn, Instagram). I understand that once my image has been posted via social media (Facebook, LinkedIn, Instragram) it can be taken down however may remain on the virtual network.

I consent to the following:
AboriginalTorres Strait IslanderOther
2. General Publishing
Yes, consent givenNo, consent not given
3. Considerations
selectability Websiteselectability Annual General Meeting (AGM)selectability Newsletterselectability media presentationsAll of the Above
4. Undertakings:

Subject to any considerations above, I understand that by giving consent, selectability can use the image/recording to promote their activities. selectability may reproduce the image or recording in any form, in whole or in part, and distribute the works by any medium including printed, the internet, CD-ROM or other multimedia.

I understand that selectability:
- will not pay me for giving this consent or for the use of my image or recording
- will return or destroy images or recordings if I withdraw this consent; and
- will not infringe the rights of any third party by exercising its rights given in this consent
5. Recipient details:

For the purpose of this consent form, the person whose images or recordings are used is known as "the recipient".
Recipient Signature
YesNot Applicable - signature provided
Please provide reasoning why verbal consent is necessary:
Recipient Name*

First NameLast Name
Date*
Witness Signature
Witness Name

First NameLast Name
Date
PART C - Recipient needs, preferences, interests, achievments and goals

Please involve the recipient in this discussion to collect information in order to support them
NEEDS - communication and disability
Unable to communicateCan communicate with verbal promptsCan communicate but is difficult to understandUses assistive communication equipmentNo identified communications support needs
Further Information
EnglishOther
AutismSpecific learning/ADD - other thanAcquired brain injuryIntellectualPhysical (please specify below)Psychiatric (please specify below)Not identifiedOther
Please specify physical/psychiatric disability
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
If yes, please specify
SittingNavigating stairsStandingWalkingPersonal hygiene (showing/toileting)
NEEDS - Health
Details of any medical conditions/medical alerts or allergies
(e.g. epilepsy, asthma, diabetes, etc.)
YesNo
YesNo
BOOK IN AS SOON AS POSSIBLE WITH GENERAL PRACTICIONER
Behavioural management planDiabetes management planDysphasia management planEpilepsy management planIndividual management plan for mental health and wellbeingSwallowing difficulties management planOther
YesNo
PLEASE UPLOAD A COPY/COPIES TO RECIPIENT FILE ON TRACCS
YesNo
If yes, please specify
PLEASE UPLOAD A COPY/COPIES TO RECIPIENT FILE ON TRACCS
YesNo
YesNo
If yes, please specify
YesNo
If yes, please specify
YesNo
If yes, please specify
K5

The following five questions ask about how you have been feeling in the last four weeks. For each question, select the option that best describes the amount of time you've felt that way.
Please note, if this is being completed for a recipient that is referred to CPS, it is mandatory under this contract, that the K5 is completed for all CPS recipients.

TOTAL
Reason why not completed:
Scoring:The K5 Total score is based on the sum of K5 item 01 through to 05 (range: 5-25). If any item has not beencompleted (that is, has not been marked 1, 2, 3, 4, 5), it is excluded from the calculation and not counted as a valid item. If any item is missing, the Total Score will not be achieved.

Minimum possible score of 5 and maximum possible score of 25. Low scores indicate low levels of psychologicaldistress and high scores indicate high levels of psychological distress.
- low/moderate 5-11
- high/very high 12-25
- not completed/invalid.
Individual Support Plan

In line with the selectability service delivery manual, the Individual Management Plan is to be used to undertake an assessment of individual needs of the recipeint being supported so that these needs are being appropriately addressed and responded to within resource capability.
A. Signs/Indicators that the recipient is having a bad day*
What should we look out for to know if you are having a bad day or feeling unwell?
B. Triggers*
What kinds of things trigger 'a bad day' or the start of feeling unwell?
C. Self-Management*
What things do you find calm you down, make you feel good, relax you or de-stresses you when you are having 'a bad day'? (e.g. feeling miserable, cranky, or upset)
D. Prevention*
What can we do to help you when you feel like you are having 'a bad day'? (e.g. get you out of a crowded room)
Preferences
MaleFemaleUnspecifiedOther
Does not identify as Aboriginal/Torres Strait IslanderAboriginalTorres Strait IslanderCALD (Culturally and Linguistically Diverse)Other
Religious or cultural beliefs
if applicable
MaleFemaleNo PreferenceTo be determined by Team LeaderKeep shift times and workers the same
Desired Worker Attributes
include public holidays
YesNo

Other information
e.g. regular depot appointments
Interests
Hobbies/Interests
Clubs/groups/sporting activities
Achievements
Things you have achieved in your life to date
Unique Strengths
Interesting things about the recipient (that they would like to share)
Emergency Disaster Assessment
Communication

In the event of emergency/disaster who does the recipient identify as their trusted person for helpful information?
Trusted Person Name*

First NameLast Name
Trusted Person Phone Number*
Trusted Person Email
example@example.com
Management of health in the event of an emergency or disaster
Where has the recipient stated they keep their health information?*
If recipient does not know, encourage them to speak with doctor and/or family.
How will the recipient identify how they will manage/monitor health/medical treatment in the event of emergency?*
If recipient does not know, encourage them to speak with doctor and/or family.
Has the recipient identified that they are able to adjust any of their supports during an event of an emergency/disaster?*
What would this look like for them?
Individual Support Plan
NDIS Plan Start Date*
NDIS Plan End Date*
How will my strengths help me achieve my goals?
Optional
Goals/Individual Support Plan

Recipient's identified recovery support needs and goals: e.g. - Increasing social and community participation by exploring areas of interests/vocational aspirations/travel/friendships/family relationships/independence & self-care/confidence/budgeting & saving/health etc.
NDIS Recipients
(list NDIS stated goals from their NDIS plan)
Goal 1*
Requested support/how it will be achieved
What's needed
No progress (0)Small gains (1)Good progress (2)Achieved goal (3)
Goal 2*
Requested support/how it will be achieved
What's needed
No progress (0)Small gains (1)Good progress (2)Achieved goal (3)
Goal 3*
Requested support/how it will be achieved
What's needed
No progress (0)Small gains (1)Good progress (2)Achieved goal (3)
Goal 4
Requested support/how it will be achieved
What's needed
No progress (0)Small gains (1)Good progress (2)Achieved goal (3)
Goal 5
Requested support/how it will be achieved
What's needed
No progress (0)Small gains (1)Good progress (2)Achieved goal (3)
Third Party Input/Assistance to Complete

(Please only complete if applicable)
If the recipient was unable to complete sections of Part C, please list below which sections and the reason why.
YesNo
Name

First NameLast Name
Relationship to recipient
Communication and DisabilityHealthIMPPreferencesInterests/Achievements/StrengthsGoals/Individual Support Plan
Reason not completed by recipient
I have discussed the following topics with my selectability support provider during this meeting:
Individual Support Plan (ISP) process - NDIS onlyIndividual Management Plan (IMP)Rights and Responsibilities (12 monthly)Privacy and Confidentiality Policy (12 monthly)Recipient Feedback Pathway explained
When I sign this plan, I am saying that this is a plan that I had full input into and have agreed to as a plan for myself and selectability to work on together.

I know that I will be able to revisit the plan whenever I want to, to add or chance parts as my needs and goals change.
Recipient Signature
YesNot Applicable - signature provided
Please provide reasoning why verbal consent is necessary:
Recipient Name*

First NameLast Name
Date*
OPG consent on file
YesNo
Legal Representative Signature
Legal Representative Name

First NameLast Name
Date
selectability Employee Signature*
Date*
Next Review Date*
Risk Factor Assessment

Must be completed
Low levels of attachment between family members (parent-child, sibling relationships)Past or current substance abusePerceived caregiver stressSocial isolationPower and control issuesPoor health and wellbeing, including social determinants such a low income, inadequate housing, etc.Negative attitudes towards people with a disability demonstrated by family membersHigh levels of dependency (either on or by the person with a disability)Lack of awareness and use of formal supportsHistory of family violence and attitudes suggesting a tolerance of family violenceNo risks identified
Strategies to reduce risk
Social isolation and lack of close relationshipsCommunication difficultiesChallenging or disruptive behaviourRisk taking and reckless behaviourHistory of drug and alcohol useCriminal history (Been to jail)Trouble with the police or courts (DVO, AVO)History of inappropriate sexual behaviourHigh tolerance of violenceHistory of attempted suicide and/or self harmHistory of poor compliance with medications, treatment, and servicesNo characteristicsOther
Strategies to reduce risk
This list is not exhaustive and other factors may also contribute to or increase a person's risk
WHS Assessment

Permission For Work Health & Safety Check - Recipient's Home
Work Health and Safety Assessment Checklist - Recipient's Home

What does this mean?

As per the Work Health and Safety Act 2011, selectability must ensure, as a primary duty of care, the health and safety of all workers and the people we support as well as the place that they work "the workplace" is safe. As the workplace in this instance is actually your home - we must inspect it for safety issues.

Your permission

selectability requests your permission for our workers to undertake an assessment of your home and complete the checklist below. The process will also ensure any areas that you may need to address to ensure there is no risk to your own health and safety.

In addition, we would like to ask some questions about things that stress you so that we can ensure our workers provide supports for you so that your emotional safety and theirs is supported.

Safety report findings

We will provide a report back to your about our findings bringing any issues to your attention that needs fixing.

I agree for a workplace health and safety inspection and discussion to occur
Recipient Name*

First NameLast Name
Recipient Signature
YesNo, signature provided
If verbal consent provided, please state reason below
OPG consent on file
Date*
- Please note if providing Community Access support - only the 'outside the residence' section should be completed
- For - in home care please complete whole assessment (relevant fields that workers will be accessing)
Work Health and Safety Assessment Checklist

Recipient's Home (please read the following/paraphrase to the recipient)
As the 'workplace' in this instance is actually your home - we must inspect it for safety issues. Thank you for providing permission to inpect it - we will provide a report back to you so that you will also know what areas of the home may provide any problems to you or your worker/s so that it can be addressed to ensure risk to health and safety is minimised.
Recipient Name*

First NameLast Name
Recipient Address*

Street Address

Street Address Line 2

CityState

Postal Code
Date of Inspection*
Outside the residence
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
PLEASE INDICIATE LEVEL OF ACCESS TO RECIPIENT'S HOUSE
Community Access Only - please proceed to remainder of intake formInside residence - please proceed to complete areas of access on WHS form below
Inside the residence
GENERAL - Are the following safe?
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
KITCHEN - Are the following safe?
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
LAUNDRY - Are the following safe?
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
BATHROOM - Are the following safe?
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
BEDROOM - Are the following safe?
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
MANUAL TASKS
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
YesNoN/A
If 'No' then specify the nature of hazard identified and control measures implemented
ANIMAL CARE
YesNo
What animals live at the residence?*
Who generally feeds them?*
Are they inside pets?*
Animal toileting issues?*
Is there a plan for who looks after the animals if you go away?*
Please note employees are unable to access your home when you are away, so staff are unable to provide this care service for animals.
Important Questions

Please work with the recipient to respond to the below questions
SMOKING
YesNoN/A
Please note selectWellbeing group spaces are smoke free
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
What are the normal smoking habits of the people who smoke? (where do they smoke, how are butts disposed of, how often do they smoke, etc.)*
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
DRINKING
YesNoN/A
Please note selectWellbeing group spaces are alcohol free
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
When drinking, are there any concerns?*
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
DRUG TAKING
YesNoN/A
Please note selectWellbeing group spaces are drug free
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
YesNoN/A
If 'Yes' then specify the nature of hazard identified and control measures implemented
What generally happens when this occurs?*
YesNo
Recipient signature to acknowledge rights of LSW
YesNot Applicable, signature provided
If verbal consent provided, please state reason below
OTHER ISSUES
Other issues not identified and/or comments (recipient's residence unhealthy to work in e.g. rats/mice, food mess, clutter, personal hygience, element of danger such as others who live with consumer, neighbours, behaviours appear unsafe, etc.)*
YesNo
PLEASE NOTIFY YOUR LINE MANAGER OF ANY RISKS IDENTIFED
selectability Employee acknowledgement
I have conducted this assessment to the best of my ability. I have identified and notified the individual of any hazards. (Team Leader to provide a written report for action items to consumer)
selectability Representative Name*

First NameLast Name
Signature*
Date*
Post Consultation Checklist
Updated TRACCS recipient profileCompleted TRACCS notes for update of informationCompleted and signed Individual Service Agreement and copy provided to recipient - NDIS only
Reason if not provided
Meeting Attendees
Names of persons who attended the meeting*
Assessment completed by*

First NameLast Name
Signature*
Date*
Feedback
If the recipient would like to advise selectability of any feedback, please write in the section provided below:
Form Completion

Please press the submit button below to finish and submit this form
Should be Empty:

Rows	Name of Provider	Contact Name	Contact Details
Service Delivery
Support Coordination
Guardianship (Office of Public Guardian)
Community Mental Health Case Worker
Financial
Other
Other

Townsville	4724 6800
Mount Isa	4743 5161
Ingham	0434 743 056
Cairns	4044 8900
Charters Towers	4787 8642
Mackay	4951 2973
Palm Island	4770 1497
Rockhampton	4999 2100
Bowen	4454 0111

Rows	(AM or PM) Mon-Fri 8am-8pm
Monday
Tuesday
Wednesday
Thursday
Friday

Rows	(start and finish times) 24-hr (0800 = 8am; 1700 = 5pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

UPDATE OF EXISTING RECIPIENT INFORMATION

PART A - Recipient Information/Demographics

1. Recipient Details

2. Living Arrangements

3. Recipient Details Continued

PART B - Permission Forms

1. Consent to Collect & Use Personal Information

Mainstream Community Supports

2. Carer or Advocate Nomination Form

3. Release for Use of Images or Recordings

PART C - Recipient needs, preferences, interests, achievments and goals

NEEDS - communication and disability

NEEDS - Health

K5

Individual Support Plan

Preferences

Interests

Achievements

Emergency Disaster Assessment

Individual Support Plan

Goals/Individual Support Plan

Third Party Input/Assistance to Complete

Risk Factor Assessment

WHS Assessment

Work Health and Safety Assessment Checklist

Outside the residence

Inside the residence

Important Questions

selectability Employee acknowledgement

Post Consultation Checklist

Meeting Attendees

Feedback

Form Completion